Health and a fair society: prevention rather than cure

Britain's population is growing and ageing, yet funding for the National Health Service has stagnated for the first time since its birth. A large scale shift is needed, moving from cure to prevention, to avert future crisis.

Image: Tax Credits

The reinstatement of a genuinely national and democratic health system will have to overcome the predictable accusations of being led by dinosaurs who are 'anti-change' and wish the NHS to remain crystallised in its 1948 form. With that in mind, OurNHS will be commissioning and publishing a number of pieces on the wider, long term future of the NHS, what improvements could be made, how the institution can grow and evolve organically while remaining firmly in line with its founding principles. We start with Anna Coote on 'prevention over cure'.

Public spending on the National Health
Service has outstripped inflation every year of its life, with an average real
growth rate of 4 per cent a year between 1949/50 and 2010/11, when total
spending for health and social care
reached £137.4
billion. For the first time now, the
growth is halted. Unless the government
has a change of heart, over the next four years the NHS faces the tightest
spending regime in 50 years.

Yet everyone expects demand for health
services to grow. There’s an ageing
population and growing rates of obesity, depression and other chronic
diseases. Following global trends, we live longer, but sicker. If the NHS can’t bridge the gap between
funding and demand then services will deteriorate. To avoid that, says
the Institute for Fiscal Studies (IFS), we must choose between
‘reconsidering the range of services available free of charge to the whole
population’ and raising taxes to pay for more and better health care.

But is that really the only choice we
have? There is another option, which is
to reduce demand by preventing ill-health, so that we live longer and
healthier, needing less health care, not more.
Instead of spending all our political capital and personal energy on
‘saving the NHS’, we could be trying to tackle the causes of illness and
keeping people well.

Experts have urged policy makers to do this
for decades. Time and again, they have
warned that social and economic disadvantages cause and entrench ill-health. The
Black Report in 1980 calls for a broader understanding of the meaning of
health and how to achieve it: ‘This will include improvement in incomes as well
as better housing and environmental and working conditions’. The
Acheson Report in 1998 repeats the message: ‘The weight of scientific
evidence supports a socioeconomic explanation of health inequalities. This
traces the roots of ill health to such determinants as income, education and
employment as well as to the material environment and lifestyle.’ The
Wanless Report in 2004 warns of the dangerously high costs of failing to
prevent illness and urged the Department of Health to ‘re-orientate its role
from caring for the sick to promoting good health’. The
Marmot Review in 2010 points out that:
‘In England, people living in the poorest neighbourhoods will, on
average, die seven years earlier than people living in the richest
neighbourhoods’; these inequalities are
caused by ‘inequalities in society - in the conditions in which people are
born, grow, live, work and age.’

Mountains of evidence support the case for
tackling the underlying causes of ill-health, which are social, economic and
environmental. Rates of illness could be radically reduced over time if the
balance of investment and action were shifted towards preventing illness
instead of just treating it.

A
new report from the National Audit Office (NAO) finds that five government
departments - Health, Education, Home Office and Ministry of
Justice - each devoted a mere six per cent of their budget to preventative
programmes . Yet , as Amyas Morse, head of the NAO, confirms: ‘A concerted shift away
from reactive spending towards early action has the potential to result in
better outcomes, reduce public spending over the long term and achieve greater
value for money.’

By restraining demand in this way, we could
sensibly plan for a high-quality NHS, providing free care to those who need it
(because not all illness is avoidable) and with a long, healthy future ahead of
it, without being locked into an upward spiral of costs. Why, then, is so
little done? Why, over the decades, has
the NHS grown exponentially, gobbling up resources, with little more than four
per cent of the health budget set aside for preventing illness? If we can’t answer this question and change
direction, we’ll be stuck with the rotten choices set out by the IFS.

The
New Economics Foundation (nef)
has been exploring the reasons why preventing
harm – in social, environmental and economic terms – is popular in theory
but not in practice. First, it’s
important to understand that there are different levels of prevention. In the health sector, these may be called
‘primary’, ‘secondary’ and ‘tertiary’. ‘Primary’ measures aim to
prevent harm before it occurs and usually focus on whole populations. The ban on smoking is one example; taking a
broader view, free universal education is another. ‘Secondary’ measures aim to mitigate the
effects of harm that has already happened and focus on people considered ‘at
risk’. These would include cancer
screening, or programmes to give children in poor families a ‘good start in
life’. ‘Tertiary’ measures try to cope with the consequences of harm and focus
on specific cases, to stop things getting worse. Think of surgery to remove malignant tumours
or steroid inhalers for people with asthma.
Action at tertiary level should be a last resort. But it is entirely
dominant in the health sector. Without tackling the underlying causes of
illness, the same problems recur, turning people into ‘patients’ who keep
coming back for more treatment and care.

There are several reasons why preventing harm – especially at primary
level - takes a back seat. For one
thing, the logic of prevention cuts
against the grain of the ‘rescue principle’ that defines contemporary medicine,
as well as philanthropy and charity. Doctors, nurses, social workers, charity
workers, faith groups, philanthropic funders – with a few exceptions, they all prefer to help those who are already in
need. The greater and more urgent the
need, the stronger their commitment. As
times get harder they increasingly target their help on the most acutely ill,
the most’ at risk’. Yet people usually
fall into these categories because there has been a failure to prevent
harm.

Overcoming this kind of barrier
means tackling professional culture and status, and changing attitudes,
hierarchies, incentives and regulatory regimes. Crucially, it means challenging
the ethical implications of clinging to the status quo. When does one cross the
line between (a) practicing one’s profession to the best of one’s ability, and
(b) securing one’s own employment, income, identity and status by failing to
prevent the needs that one is trained to meet?
The domain of healthcare and the pre-eminence of clinical treatment are
strongly defended by rich, high-status, predominantly male and mightily
established professional institutions.
Outside the City of London, there are no cohorts with comparable powers. The point is not that these institutions
actively oppose the prevention of illness.
They instinctively employ what could be called ‘passive resistance’:
agree that it is a good thing and do little or nothing about it.

At the same time, new
pharmaceuticals and awe-inspiring clinical developments have changed
expectations. We are encouraged to want more and better interventions, to
repair previously unrepairable bits of our bodies, and to stave off death (it
would seem) indefinitely. Supply drives
up demand: it may work in open markets, but it can’t work for long in a
publicly funded service with a finite budget.

Evidence presents another kind
of barrier. If you give an arthritic patient a hip operation, you have an
immediate, tangible result that you can measure. The same goes for most
tertiary and secondary activities. Move upstream to prevent arthritis, for
example by encouraging healthy eating and exercise, and you find that it takes
much longer for interventions to have an effect. The causal pathways become
more complex and indistinct, creating an evaluation bias against primary
prevention.

It is much easier, especially in
these days of ‘evidence-based policy making’, to make the case for investing
public (or even charitable) funds in interventions where the outcomes are
certain, and where measurable benefits can be reaped in the near future. Politicians want to show their voters that
their policies deliver clear results about things that really matter to them,
before the next election. The political cycle, leaning heavily towards
short-term crowd-pleasing, puts a firm brake on the longer-term ambitions of
preventing harm.

The voting public have an
enduring love affair with the rescue and cure component of the NHS. White coats
and stethoscopes, flashing blue lights, emergency rooms. Open heart surgery,
MRI scanners, trolleys being rushed along corridors. We love it all and we want
to save it. Yet in fact, what is eating
up the healthcare budget is not all that telegenic heroism, but the unglamorous
daily grind of processing people with largely avoidable chronic conditions –
heart disease, diabetes, arthritis, asthma, hypertension and depression, to
name but a few. Effective primary intervention would cost far less than coping
with these conditions once they have set in. It would call upon other budgets –
for education, housing, transport, work and benefits, for example.

But for the health budget, there
are problems of overlap and timing. For
political and humanitarian reasons, there would have to be increased investment
in primary prevention without much noticeable decrease in secondary and
tertiary measures. When we consider how rescue and cure tend to have immediate,
tangible and measurable results, while primary measures are long-term, less
concrete, less predictable and harder to measure, the odds seem stacked against
shifting the balance of investment towards prevention.

When William
Beveridge planned a free national health service, he saw it as an investment
that would help prevent illness and therefore reduce expenditure on healthcare
in future. He couldn’t foresee the complex ways in which, over time, new
technologies, profit-driven pharmaceutical companies, powerful professional
interests and changing demographics would fuel expectations and demands,
driving up costs inexorably. Now the NHS
is in mortal peril. Unlike us, it
doesn’t have to die one day. But if we
don’t tackle the underlying cause of its life-threatening illness – the
avoidable growth in demand for services – we’ll have more than the neo-liberal
ideologues to blame for its demise.

This article is published under a Creative Commons Attribution-NonCommercial 3.0 licence.
If you have any queries about republishing please contact us.
Please check individual images for licensing details.